Clinical care rendered by physicians and other health care providers is reviewed for utilization management, quality of care, and other review or analytic functions by reviewing entities charges with these functions. Utilization management is usually performed by a health maintenance organization (HMO) or other managed care organization (MCO).
When a healthcare provider (HCP) examines and treats a patient, the HCP records the examination in a clinical chart. Under industry custom, designated personnel at the health care site extract clinical information from the chart and transmit the clinical data to the reviewing entity by telephone or fax.
At the reviewing organization, personnel manually input this clinical data into an electronic form with one or more text fields. The information is then reviewed by one or more professional personnel to determine appropriateness of care. Determinations of the appropriateness of care are then communicated back to the health care site by phone or fax (negative determinations also require a formal letter of denial).
Moreover, because the clinical information has been electronically input into text fields without any format, the reviewing organization lacks the ability to electronically evaluate this data for appropriateness of care. Determinations are made manually. Determinations are often inconsistent for similar clinical situations by the same reviewer or among multiple reviewers. There is almost no way to systematically evaluate this data among multiple clinical episodes to see patterns of care.
As may be gathered from the description above, the process for submitting and reviewing clinical records is cumbersome and time consuming. Both the HCP and the MCO dedicate personnel and other resources to the sole task of managing and processing clinical data. Accordingly, there is a need for a system that facilitates the generation and processing of clinical records, which provides sufficient data to the MCO, and which facilitate the speedy processing and authorizing of the records.